Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elevate Care Palos Heights during CMS and state inspections, most recent first.
Failure to individualize ADL care plans and anticoagulant education: The facility did not develop individualized ADL care plans for multiple residents who needed staff help with personal hygiene, including shaving, and staff described grooming as a general task rather than resident-specific care. Interviews showed the DON, MDS/Care Plan Coordinator, and Restorative Director all recognized that care plans should be individualized, yet the records reviewed lacked specific ADL interventions. The facility also failed to properly align anticoagulant/antiplatelet care plans with physician orders for residents on Eliquis, aspirin, and Plavix, and one resident’s record lacked documented education for the resident and family.
A staff member failed to obtain permission from an alert and oriented resident before checking for incontinence and inappropriately touched the resident's vaginal area, causing the resident to feel violated and emotionally harmed. The staff member admitted to not getting explicit permission and used an improper method to check the brief. Facility policy and staff interviews confirmed that permission and proper technique are required, and the incident was reported as abuse.
A resident and their family alleged abuse by staff, which was reported to the administrator by an LPN. However, the administrator did not notify the state department within the required two-hour window, as confirmed by the VP of Operations. The DON later reported the allegation, but the delay violated the facility's abuse reporting policy.
The facility did not maintain a safe kitchen environment, with broken floor tiles present throughout the kitchen for several years and a non-functioning exhaust fan above the stove, resulting in excessive heat. Staff confirmed these issues had persisted over time, affecting food preparation for all residents.
A resident with moderate cognitive impairment had personal funds deposited with the facility, but after the resident's death, the family reported not receiving the money. The administrator and DON gave conflicting accounts of the release of the funds, and there was no documentation or signed receipt to confirm the transaction, indicating a failure to properly record and manage resident funds.
Multiple residents, including those with cognitive impairments and dependence on toileting hygiene, were found in unsanitary conditions with soiled briefs and linens, and strong urine and feces odors were present in hallways and common areas. Housekeeping staff were unaware of the odor sources, and the facility did not meet its policy for maintaining a clean, odor-free, and comfortable environment.
Three female residents with cognitive impairment who were dependent on staff for toileting hygiene were not provided timely incontinent care, resulting in them being found with urine and feces-soaked briefs, pads, and linens, and strong odors in their rooms. Care plans and facility policy required regular checks and perineal care after each episode, but these were not followed, as confirmed by a CNA and the DON.
The facility failed to ensure call lights were within reach for two residents, one with cerebral palsy and contractures, and another with multiple sclerosis. The first resident's custom call light was not accessible, and the second resident's call light was found on the floor. Staff confirmed that call lights should have been within reach to accommodate the residents' needs.
The facility failed to follow infection control practices for respiratory equipment, affecting two residents. A resident's nebulizer mask was left uncovered, and another's CPAP mask was not stored properly. Staff acknowledged the equipment should be stored in labeled plastic bags, as per facility policy.
A resident with a right arm precaution bracelet and signage had blood drawn from the wrong arm by a third-party phlebotomist, leading to swelling. The facility's staff were unaware of the lab visit, and the precaution was documented through various means. The phlebotomist did not adhere to communication and site selection guidelines.
A facility failed to protect a resident from mental abuse by a staff member, leading to the resident feeling unsafe and untrusting. The resident reported an incident where a dietary aide refused food and used derogatory language. Despite the aide's termination, the administrator rehired him as a CNA, allowing him to provide direct care, which continued to distress the resident.
A resident reported that a dietary aide repeatedly entered her room and took her personal beverages without permission, despite her requests for the aide to stop. The resident, who is cognitively intact and has Conversion Disorder and Generalized Anxiety Disorder, expressed discomfort with the aide's actions, which violated the facility's policy against misappropriation of resident property.
The facility failed to report an allegation of misappropriation of property and did not timely report an allegation of physical abuse to IDPH. A resident reported a dietary aide took a beverage, which was not recognized as misappropriation. Another resident reported rough care by a CNA, but the administrator delayed reporting due to not checking emails over the weekend. The facility's policy requires immediate reporting, which was not followed.
A facility failed to investigate an allegation of misappropriation of property when a resident reported that a dietary aide was taking their personal drinks. The administrator did not interview other residents or staff and could not provide documentation of an investigation, contrary to the facility's abuse policy.
The facility failed to maintain accurate records of controlled substances, affecting 15 residents. The Director of Nursing and Nursing Supervisor admitted to shredding forms used for recording the use of controlled substances, which were not uploaded into the electronic health record. The facility's policy required detailed drug disposition records, but these were not maintained, leading to discrepancies. The affected residents included those discharged, still residing, or expired, with medications like hydrocodone/acetaminophen and alprazolam involved.
A resident suffered a fracture to the left distal tibia after being improperly transferred using a mechanical lift by two CNAs, one of whom was new and in training. The incident was not immediately reported or documented, and the facility's investigation revealed a lack of adherence to safety protocols and insufficient staff training on mechanical lift use.
Failure to Individualize ADL Care Plans and Anticoagulant Education
Penalty
Summary
The facility failed to develop individualized ADL care plans for eight residents, including residents with diagnoses such as hemiplegia and hemiparesis following cerebral infarction, hypokalemia, weakness, heart failure, COPD, and other conditions. Several of the residents were cognitively intact based on BIMS scores, while one resident was cognitively impaired. Review of the care plans for residents who required staff assistance with ADLs showed no individualized interventions for personal hygiene needs, including shaving. Facility staff stated that the care plans used a general approach for grooming and that mobility was the main focus, even though the residents’ needs were described as individualized and should have been reflected in the care plans. During interviews, the DON acknowledged that care plans should be individualized according to each resident’s needs. The MDS/Care Plan Coordinator stated that restorative staff handled ADL care plans and that she coordinated other sections of the MDS and care planning process. The Restorative Director stated that she completed ADL, fall, and restorative care plans and that each resident’s care plan should include specific interventions and intended outcomes. She also stated that the company’s care plan format used grooming as standard care and did not include a separate grooming plan, even though she said the care plan should be personalized for each resident. The report also identified deficiencies in anticoagulant/antiplatelet education and care planning. One resident receiving Eliquis had bruising and discoloration on both arms and legs, and the care plan included instructions to avoid aspirin and NSAIDs even though the physician order and MAR showed concurrent aspirin use. The DON, MDS/Care Plan Coordinator, and Medical Director discussed the mismatch between the care plan and the physician orders. Another resident taking aspirin and Plavix had no baseline or comprehensive care plan for antithrombotic/antiplatelet medications. The record review also showed that one resident’s medical record did not contain documented education for the resident and family members regarding anticoagulant medication.
Failure to Obtain Permission and Inappropriate Touching During Incontinence Check
Penalty
Summary
A staff member failed to obtain permission from an alert and oriented resident before checking for incontinence and inappropriately touched the resident in the vaginal area. The resident, who had multiple medical diagnoses including a femur fracture, congestive heart failure, diabetes, atrial fibrillation, chronic kidney disease, COPD, anxiety disorder, major depression, obesity, and GERD, reported feeling angry, violated, and emotionally harmed by the incident. The resident described waking up to the staff member's hand between her legs under her brief, touching her vaginal area, and stated that she pushed the staff member's hand away and told him to leave. The resident subsequently reported the incident to her family, who contacted the police, and expressed a desire to pursue the matter criminally. The staff member involved stated that he announced himself and informed the resident he was there to check if she was dry, but omitted obtaining explicit permission before touching the resident. He reported patting the resident's brief to check for wetness and did not provide further incontinence care during that shift. The staff member acknowledged that the resident was alert and oriented and typically requested assistance when needed. Other staff interviews confirmed that facility practice requires staff to announce themselves, inform residents of intended care, and obtain permission before touching alert and oriented residents. It was also noted that patting or massaging a brief is not an accepted practice for checking incontinence. Facility policies reviewed indicated that residents are to be treated with respect and dignity, and that staff must explain procedures and obtain permission before providing care, especially for alert and oriented residents. The policies also prohibit abuse, neglect, and mistreatment, and require the prevention of such occurrences. The resident's care plan emphasized the need for person-centered care and maintaining a supportive environment, but the baseline care plan did not include a toileting assessment. The failure to follow these protocols resulted in the resident experiencing emotional distress and reporting the incident as abuse.
Failure to Timely Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to follow its policy regarding the timely reporting of an abuse allegation for one of three residents reviewed. On 9/19/25 at approximately 10:30pm, a resident and their family alleged abuse by staff, and an LPN reported that the administrator was made aware of the allegation that night. However, the administrator did not report the allegation to the state department within the required two-hour timeframe. The Vice President of Operations confirmed that the report was not made within two hours as required by facility policy. The Director of Nursing stated that the allegation of sexual abuse was reported to the state department on 9/20/25 at 1:43pm. Review of the facility's abuse prevention and reporting policy indicated that any allegation of abuse or incident resulting in serious bodily injury must be reported to the department of public health immediately, but not more than two hours after the allegation is received. The facility's failure to report the abuse allegation within this timeframe constitutes a deficiency in following established abuse reporting protocols.
Failure to Maintain Safe and Functional Kitchen Environment
Penalty
Summary
The facility failed to maintain a safe and functional kitchen environment, as evidenced by broken ceramic floor tiles throughout the kitchen and a non-functioning exhaust fan above the stove. Observations confirmed that the kitchen floor had missing and uneven tiles, a condition that had persisted for at least five years according to staff interviews. The exhaust fan was not operational, resulting in unusually high temperatures around the stove area. Staff members, including dietary aides and cooks, reported that these issues had been ongoing, with the broken tiles present since their employment began and the exhaust fan not working on consecutive days. The dietary manager and maintenance director acknowledged the problems, stating that maintenance was aware of the exhaust fan failure and that efforts were underway to replace the broken tiles. The facility's environmental services policy requires the environment to be maintained in a manner that promotes health and safety for residents, personnel, and the public. At the time of the deficiency, 92 residents were consuming food prepared in the affected kitchen, but no specific medical history or conditions of the residents were mentioned in relation to the deficiency.
Failure to Properly Record and Release Resident Funds
Penalty
Summary
The facility failed to establish and maintain a proper system for recording and releasing resident funds in accordance with generally accepted accounting principles. Specifically, for one resident with moderate cognitive impairment, there was a lack of documentation and proof regarding the release of $200 in cash and a $400 cashier's check that were deposited with the facility. After the resident's death, the family was informed that the funds had already been released, but the family reported never receiving the money. The administrator stated that the resident's wife collected the funds prior to the resident's death, but there was no documentation or signed receipt to confirm this transaction. Interviews with staff revealed inconsistencies in the account of how and when the funds were released. The DON recalled that the administrator gave the money to the wife and daughter but might have forgotten to record it. The administrator described instructing another staff member to retrieve and hand over the funds, but admitted that the normal process of obtaining a signed receipt was not followed and no proof of the transaction was available. A review of clinical records and documentation for the relevant period showed no evidence that the funds were released to the family.
Failure to Maintain Clean, Odor-Free, and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for several residents, as evidenced by persistent foul odors and unsanitary conditions in resident rooms, hallways, and common shower areas. Observations revealed strong urine and feces smells in the 300 hallways and the common shower room. Housekeeping staff were unaware of the source of the odors and had not yet addressed the issue at the time of observation. Multiple residents were found in their beds with intense urine and feces odors, and incontinent briefs and linens were observed to be soiled and discolored with urine and feces. These conditions were directly observed by surveyors and confirmed by staff interviews. Several residents with varying degrees of cognitive impairment and dependence on toileting hygiene were affected. One resident with mild cognitive impairment was found with urine and feces-soaked briefs and soiled linens, while another with severe cognitive impairment was similarly found with feces-soaked briefs and linens. A third resident with moderate cognitive impairment was observed with soiled briefs and linens, and the hallway near her room also had a strong odor. Additionally, a resident with intact cognition reported that her room and the hallways were smelly, particularly after a roommate change. The facility's own housekeeping policy requires a clean, odor-free, and comfortable environment, but this standard was not met during the survey.
Failure to Provide Timely Incontinent Care to Dependent Residents
Penalty
Summary
Three female residents with varying degrees of cognitive impairment, all dependent on staff for toileting hygiene, were not provided timely incontinent care as required by their care plans and facility policy. Observations revealed that these residents were found in their beds with intense urine and feces odors, and their briefs, pads, and linens were soaked and discolored from urine and feces. The care plans for these residents specified that perineal care should be provided after each incontinent episode and that residents should be checked at regular intervals, including upon rising, before and after meals, at bedtime, and as needed. A Certified Nursing Assistant (CNA) reported that she began her shift at 6:00 AM but had not had the opportunity to change some of her assigned residents, including the three affected individuals, by late morning. The Director of Nursing confirmed that incontinent care should be provided at least every two hours and that the environment should be odor-free. The facility's incontinence policy also requires periodic checks and perineal care after each episode, which was not followed in these cases.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, leading to a deficiency in accommodating their needs. On January 21, 2025, a resident with cerebral palsy and contractures was observed in bed without their custom call light within reach. A Certified Nursing Assistant (CNA) confirmed the absence of the call light, which was necessary for the resident to request assistance due to their condition. The Director of Nursing (DON) acknowledged that the call light should have been accessible. Additionally, another resident with multiple sclerosis was found asking for their call light, which was on the floor and out of reach. A nurse subsequently attached the call light to the bed, ensuring it was accessible. The DON confirmed that the call light should always be within reach for this resident, who was at risk for falls due to deconditioning.
Infection Control Deficiency in Respiratory Equipment Handling
Penalty
Summary
The facility failed to ensure proper infection control practices in handling respiratory equipment, affecting two residents. One resident's nebulizer mask was observed uncovered on a dresser, with tubing that was neither dated nor labeled. A Licensed Practical Nurse acknowledged that the nebulizer mask should be covered in a plastic bag with the tubing labeled and dated, as per the facility's policy. The Director of Nursing confirmed that the nebulizer masks should be stored in a plastic bag with the resident's name and date for infection control purposes. Another resident's CPAP machine was found on a nightstand with the mask and cannula not stored in a plastic or zip lock bag when not in use. The Licensed Practical Nurse and the Director of Nursing both stated that the CPAP mask and cannula should be stored in a plastic or zip lock bag when not in use, in accordance with the facility's policy on oxygen and respiratory equipment. The resident had a diagnosis of sleep apnea and was required to wear the CPAP at bedtime, as documented in their care plan.
Improper Blood Draw from Resident with Limb Precautions
Penalty
Summary
The facility failed to ensure a proper blood draw from a resident with limb precautions, affecting one resident. The incident occurred when a third-party phlebotomist drew blood from the resident's right arm, despite the presence of a precaution bracelet and a sign at the head of the bed indicating no blood draws or blood pressures should be taken from that arm. The Director of Nursing and the primary nurse were reportedly unaware of the lab visit on the day of the incident. The resident's arm was swollen as a result of the incorrect blood draw. Interviews with staff revealed that the precaution was well-documented and communicated through various means, including a bracelet, signage, physician orders, and computer charting. The phlebotomist, who was covering for the usual staff, claimed not to have seen the precautionary indicators. The facility's phlebotomy guidelines emphasize the importance of communication and correct site selection, which were not adhered to in this instance.
Failure to Prevent Mental Abuse by Staff Member
Penalty
Summary
The facility failed to protect a resident from mental abuse by a staff member, resulting in the resident feeling unsafe and untrusting. The resident, who is cognitively intact and uses a wheelchair, reported an incident where a dietary aide refused to provide food and called her a derogatory name. The resident had previously allowed the aide to consume her personal beverages but stopped, which she believed led to the aide's negative behavior. The resident reported the incident to the facility administrator and dietary manager, leading to a meeting with her family and the termination of the aide. Despite the termination, the administrator later rehired the aide as a CNA and brought him to the resident's room to apologize. However, the apology was not specific to the incident, and the resident continued to feel unsafe as the aide was now providing direct care and entering her room. The resident expressed feeling guarded and concerned about the aide's behavior, fearing for her safety and the safety of other residents who might not be able to defend themselves. The facility's abuse prevention policy, which the aide had acknowledged, defines abuse as actions causing mental anguish. The policy emphasizes the resident's right to be free from abuse, including mental abuse. The facility's failure to limit the aide's access to the resident after the incident contributed to the resident's ongoing distress and lack of trust in the facility's ability to ensure her safety.
Failure to Protect Resident's Belongings from Misappropriation
Penalty
Summary
The facility failed to protect a resident from the misappropriation of her property, specifically her beverages, by a staff member. The resident, a cognitively intact female with Conversion Disorder and Generalized Anxiety Disorder, reported that a dietary aide, with whom she was initially friendly, began entering her room uninvited and taking her personal soda from her refrigerator. This behavior continued even after the resident expressed discomfort and asked the aide to stop entering her room, especially after she got a roommate. The incident was reported to the facility administrator, who documented the resident's concern that the dietary aide was taking and drinking her drinks. The facility's abuse prevention and reporting policy, which prohibits misappropriation of resident property, was acknowledged by the dietary aide prior to the incident. Despite this, the aide's actions led to a deficiency in protecting the resident's belongings, as the aide continued to enter the resident's room and take her beverages without permission.
Failure to Timely Report Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to report an allegation of misappropriation of property for a resident and did not timely report an allegation of physical abuse for another resident to the Illinois Department of Public Health (IDPH). These deficiencies were identified during a review of three residents for abuse. One resident, a cognitively intact female with conversion disorder and generalized anxiety disorder, reported that a dietary aide took a beverage from her room. The facility administrator did not recognize this as misappropriation of property and failed to report it to IDPH until the following day. Another resident, a female with multiple fractures and autism, reported rough care by a CNA to her family member, who then emailed the facility administrator. The administrator did not check the email over the weekend, resulting in a delay in reporting the incident to IDPH. The CNA continued to provide care to the resident after the allegation was reported. The facility's policy requires immediate reporting of such incidents, but this was not adhered to in these cases.
Failure to Investigate Allegation of Misappropriation
Penalty
Summary
The facility failed to provide evidence of a thorough investigation into an allegation of misappropriation of property involving a resident. The incident involved a resident who reported that a dietary aide was taking and drinking their personal drinks. The administrator acknowledged being informed of the concern but did not interview other residents or staff about the allegation and was unable to provide any written documentation related to an investigation. The facility's abuse policy requires interviews with residents and employees who have interacted with the accused to determine if there have been any prior incidents of misappropriation, but this procedure was not followed in this case.
Failure to Maintain Controlled Substance Records
Penalty
Summary
The facility failed to maintain a proper record of controlled substances, affecting 15 residents who were reviewed for the disposition of controlled drugs. During the survey, it was found that the facility did not account for each dose of narcotic medications given and disposed of, as required by their policy. The Director of Nursing and Nursing Supervisor admitted that they were responsible for disposing of controlled medications but were unable to provide documentation for each dose used or disposed of. The forms used for recording the use of controlled substances were shredded and not uploaded into the electronic health record, which was against the facility's policy. The facility's policy required that the drug disposition record include specific details such as the resident's name, date of drug destruction, name and strength of the drug, prescription number, quantity destroyed, method of destruction, and signatures of witnesses. However, the forms provided by the Director of Nursing did not include the method of destruction, and the forms were not part of the resident's individual record. The facility did not have a policy stating that these forms needed to be preserved in the resident records, leading to discrepancies in the accounting of controlled substances. The residents affected by this deficiency included those who were discharged, still residing in the facility, or had expired. The medications involved were various controlled substances such as hydrocodone/acetaminophen, pregabalin, alprazolam, oxycodone/acetaminophen, and others. The facility's failure to maintain accurate records of these medications was confirmed by the pharmacist and medical director, who stated that the nurses were expected to document the count of each medication using the count sheet that accompanied the medication dispensed. This documentation should have been part of the resident's medical record for future reference and review.
Improper Use of Mechanical Lift Leads to Resident Injury
Penalty
Summary
The facility failed to safely transfer a resident using a mechanical lift, resulting in an injury. During the transfer of a resident from a wheelchair to a bed, the resident's left foot bumped the footboard, leading to a fracture of the left distal tibia. This incident involved two CNAs, one of whom was new and undergoing orientation. The CNAs were unable to explain how the mechanical lift pad shifted during the transfer, which contributed to the resident's injury. The resident involved in the incident was alert and oriented with a BIMS score indicating moderate impairment. The resident had a history of falling, difficulty in walking, and muscle weakness, which necessitated the use of a full-body lift for transfers. Despite the resident's condition, the CNAs did not report any immediate signs of pain or injury following the incident, and the LPN on duty did not document the occurrence in the resident's progress notes. The facility's policy requires that mechanical lifts be operated by two people to ensure resident safety. However, the CNAs involved did not follow proper procedures, as evidenced by the shifting of the lift pad. The Director of Nursing was not informed of the incident until days later when the resident began to show signs of pain. The facility's investigation revealed a lack of documentation and communication regarding the incident, and there was no evidence of prior training for staff on the use of mechanical lifts.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Palos Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aliya Of Crestwood | 1.4 mi | ★★★★★ | 5 | 0 |
| Avantara Palos Heights | 2 mi | ★★★★★ | 29 | 0 |
| Harmony Palos | 2.1 mi | ★★★★★ | 9 | 0 |
| Thryve Of Crestwood | 2.2 mi | ★★★★★ | 2 | 0 |
| Crestwood Terrace | 2.2 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.